[Correlation between chronic obstructive bronchial disease and colonic anastomosis dehiscence in the elderly]. / Correlazioni tra broncopatia cronica ostruttiva e deiscenza dell'anastomosi colica in età geriatrica.

BACKGROUND: Anastomotic leakage remains a major complication after large bowel surgery. Chronic obstructive pulmonary disease is frequent disease in the elderly. AIMS: The authors want to analyze the correlation between systemic tissue hypoxia, resulting from chronic obstructive pulmonary disease and anastomotic leakage in large bowel surgery in a group of patients over 65 years. PATIENTS AND METHODS: In the period 1979-2001 at our surgical Department, 590 patients underwent colorectal surgery; 211 elderly patients (> 65 years) with large bowel anastomosis were selected. In 29/211 (13.7%) chronic obstructive pulmonary disease was diagnosed. The group of patients affected by chronic obstructive pulmonary disease was defined as group A; the other, as group B. The incidence of anastomotic leakage in patients with and without chronic obstructive pulmonary disease was evaluated. RESULTS: The overall incidence of anastomotic leakage was 5.6% (12/211); a difference in the incidence of anastomotic leakage was found in the group A vs. B: 7/29 (24.1 %) in the group A were affected by dehiscence vs. 5/182 (2.7%) of group B. This difference was statistically significant (p = 0.001). CONCLUSIONS: Chronic obstructive pulmonary disease can be a factor increasing the risk of anastomotic leakage. The elderly patient is often affected by chronic obstructive pulmonary disease and consequently show an higher risk of colonic anastomotic failure than younger patients.

Perineal pilonidal sinus. Case report.

Pilonidal sinus is a very common disease and its most frequent location is in the presacral area. Other locations are extremely rare. We describe the case of a 28-year-old white man, a baker by profession, with a swelling around the right side of the anus, pain with burning, itching and seropurulent secretion which had been present for 7 months. A physical examination demonstrated the presence of multiple cutaneous fistulas. A fistulography and the endoscopy demonstrated the absence of fistulas-in-ano. Moreover, MRI confirmed the diagnosis of a perianal mass not communicating with the anal canal. Surgical exploration revealed the presence of hair and an excision of the mass with fistulas was performed. Healing was rapid and uncomplicated. Perineal pilonidal sinus with foreign body inflammatory reaction was the histological diagnosis.

One-day vs standard thyroidectomy. A perspective study of feasibility.

BACKGROUND: The aim of this randomized controlled trial is to evaluate the feasibility of one-day thyroidectomy, comparing the results of this method vs standard thyroidectomy. METHODS: From June 2000 to June 2001, 110 patients underwent total thyroidectomy under general anesthesia for thyroid disease. The patients were randomized into 2 groups: in group A (40 patients) we used the one-day thyroidectomy; in group B (70 patients) we employed standard thyroidectomy. In both groups postoperative mobilization was immediate and the mean postoperative hospitalization stay was 21 hours (range: 18-24) in group A and 60 hours (range: 21-120) in group B. The mean follow-up was 10 months (range: 6-18 months). RESULTS: The patients of group A showed hypoparathyroidism with temporary hypocalcaemia in 3 cases (7.5%) vs 5 (7.1%) of group B; this finding was not statistically significant. No cases of definitive hypoparathyroidism, nor lesions of RLN, of the external branches of the superior laryngeal nerve, nor postoperative hemorrhage were observed in either group. CONCLUSIONS: The one-day thyroidectomy was found to be a safe, feasible and cost effective procedure, it is convenient for both the patient and the surgeon, and offers the same immediate and long-term results as the standard thyroidectomy in selected patients.

Rectal perforations. Personal experience and literature review.

BACKGROUND: Rectal perforation presents high morbidity and mortality and its treatment is still not standardized, it is still rather based on the surgeon's personal experience. This retrospective trial, with a literature review, aims to define these types of lesions, and tries to identify the diagnostic and therapeutic options able to reduce related morbidity and mortality. METHODS: On 1175 operations conducted for colo-rectal emergency, over a ten-year period at our institution, fourteen consecutive patients (1.2%) were seen and treated for rectal perforation. In 43% of cases the treatment consisted in Hartmann's procedure, in the 28.5% ones in rectal wound repair with diverting colostomy and in 28.5% left in diverting colostomy alone. RESULTS: There were no postoperative complications in 86% of patients, and no deaths from sepsis. In 28.5% of cases intestinal continuity was restored at our institution. CONCLUSIONS: Our results demonstrate that a standardized protocol which is based on patients' conditions, type and degree of rectal injury and of peritonitis, must be followed in order to determine the type of surgical option and consequently to reduce the morbidity and mortality related to rectal perforation.

Trabucco versus Rutkow versus Lichtenstein techniques in the treatment of groin hernia. A controlled randomized clinical trial.

BACKGROUND: The aim of this prospective study is to compare the results of the 3 most common tension-free techniques usually performed (Trabucco vs Rutkow vs Lichtenstein). METHODS: From January 1993 to December 1995 we selected 150 patients to undergo elective surgery for primary monolateral inguinal hernia. The patients were randomized into 3 groups: in group A (53 patients) we used the original plug and patch technique proposed by Rutkow and Robbins; in group B (47 patients) we introduced a modification to the technique originally described by Trabucco, anchoring the plug to the internal ring, fixing the patch on the pubic tubercle and on the tails of the mesh; in group C (50 patients) the Lichtenstein technique was employed. The study was performed using a randomized single blind controlled trial (RCT). The statistical analysis of our data was performed by c2 test and confirmed by the Fisher exact test. The mean follow-up was 73 months (range:58-94). RESULTS: We had no statistically significant differences in the results of the 3 groups. Otherwise the patients of group C showed a significantly higher incidence of suprapubic or more rare inguino-scrotal haematoma (p<0.0033 C vs B; p <0.0038 C vs A). The mean recovery time was between 12 and 14 days in the 3 groups, with no significant statistical differences. CONCLUSIONS: The only difference observed is a higher incidence of postoperative haematoma in group C.

Microsurgical treatment of varicocele in outpatients using the subinguinal approach.

BACKGROUND: The aim of this study is to analyze the results of a group of patients who underwent subinguinal microsurgical varicocelectomy using local anaesthesia in one-day-surgery. METHODS: From 1997 to 1998 150 patients were selected from the whole group of patients who underwent surgical treatment for varicocele. The varicocele was always on the left side and the mean age was 27.1 years (range: 16-43). The diagnosis was based on clinical features (testicular pain or scrotal sensation), physical examination and Doppler ultrasound. Where there was infertility with abnormal semen analysis and/or patient's intolerance to the symptoms, surgery was suggested. The patients underwent varicocelectomy by sub-inguinal approach using local anaesthesia. The microsurgical technique of dissection was performed. RESULTS: All operations were performed on an outpatient basis (post-operative stay: 3-7 hours) and the operating time was 20 to 45 minutes. Follow-up was performed by physical examination, doppler ultrasound and semen analysis. Immediate and long-term complications were: 7 (4.7%) transient pain, 3 (2.0%) ecchymosis, 1 (0.7%) transient hydroceles and 1 (0.7%) permanent hydroceles, 2 (1.3%) palpable recurrence, 2(1.3%) doppler recurrence and 1 (0.7%) long-term recurrence, 0 testicular atrophy. 120/150 (80%) patients showed an improvement of semen analysis and 19/41 (46.3%) patients with infertility achieved a pregnancy with the partner. CONCLUSIONS: Microsurgical treatment of varicocele in outpatients by subinguinal approach is a safe and reliable procedure. It is performed in local anaesthesia, preserves the lymphatics, spermatic artery and vas and in our experience showed an improvement of semen analysis and pregnancy rates with minimal morbidity.

Treatment of chronic pilonidal sinus with local anaesthesia: a randomized trial of closed compared with open technique.

OBJECTIVE: To compare open with closed treatment of chronic pilonidal sinus. PATIENTS AND METHODS: From 1993 to 1996, 100 patients were submitted to excision of chronic pilonidal sinus, with local anaesthesia and were randomized in two groups: group A in which open treatment and group B in which direct suture were performed. The follow-up, ranging from 37 to 89 months, was performed by outpatient visits or by phone. RESULTS: Short-term results showed 6 (12.0%) post-operative complications in group A vs 10 (20.0%) in group B. Long-term results showed 9 (18.0%) complications in group A vs 7 (14.0%) in group B. Mean wound healing was 58 days (range: 29-93) in group A vs 12 (range: 9-61) in group B. The return to normal activity was 25.7 (range: 11-77) vs 10.4 (range: 5-32). Wound healing and the return to normal activity were the only statistically significant differences. CONCLUSIONS: Regarding morbidity neither technique has particular advantages over the other. The closed technique produced quicker wound healing and a quicker return to normal activity.

[Obstructive jaundice caused by hydatid cyst rupture in main bile duct]. / Ittero ostruttivo da rottura di cisti idatidea nella via biliare principale.

Hydatid hepatic cyst rupture into bile duct is a complication of hydatid disease. The rupture is more frequent in right or left epatic duct and occasionally in common bile duct (7-9%). A 50-year old man came to emergency room owing to jaundice, fever and abdominal pain. TC show an hydatid cyst with daughter's cyst of left liver and dilatation of biliary tree. Laboratory data of significance included an increased of liver function tests (Bilirubin, Alkaline ph., SGOT, SGPT), VES and leukocytosis. The patients was surgically treated, by total pericystectomy, colecystectomy and coledocotomy with lavage o common bile duct; finally we placed one Kehr drainage and two abdominal drainage. After 15 days of postoperative hospitalization patient was discharged. The best treatment of hydatid cyst is total pericystectomy (when possible). An alternative surgical treatment is possible for the presence of communication with biliary tree. ERCP is very important for a correct diagnosis and for a complete surgical treatment.

An unusual complication resulting from surgical treatment of periampullary tumours.

BACKGROUND AND METHODS: The authors describe the rising of four postoperative pancreatic pseudocysts in a series of 20 patients treated for periampullary tumours by pancreaticoduodenectomy (PDT), with the closure of pancreatic stump, between 1989-1996. The operation was always performed by the pylorus-preserving technique according to Traverso-Longmire. RESULTS: In four patients (20%) 3, 4, 4, and 8 months after PDT with closure of the pancreatic stump, the authors observed the development of pseudocysts (PPC) in the pancreatic remnant. All these patients previously had a pancreatic fistula. Three symptomatic patients underwent surgical drainage of the pseudocyst in a jejunal loop (2) or in the stomach (1); in the asymptomatic patient, the clinical feature and the size of the cyst allowed for conservative treatment. In 2 cases PPC was the consequence of a pancreatic fistula evolved in acute pancreatitis of the stump. The PPC drained by cystogastrostomy appeared 4 months after the closure of the pancreatic fistula: the pancreatic stump was completely substituted by a cyst presenting a communication with the pancreatic duct. CONCLUSIONS: The authors conclude that PPC is a rare complication of the pancreatic resection that results from acute or chronic pancreatitis; sometimes pathogenesis is due to a cyst resulting from the pancreatic duct occlusion by phlogistic tissue as a consequence of the surgical suture.